Memorandum by the General Medical Council
PROCEDURES RELATED TO ADVERSE CLINICAL INCIDENTS AND OUTCOMES IN MEDICAL CARE (ACI 167)
1. We have been invited to submit a written memorandum to the Health Committee on their terms of reference:
"To examine the adequacy and effectiveness of the procedures, including investigative procedures, undertaken following adverse clinical incidents and outcomes in medical care. In particular, to examine the availability and accessibility of information, support and advice to patients and their relatives and carers."
2. The GMC has been granted extensive powers by Parliament to regulate individual members of the medical profession. Those powers include dealing with doctors who are unfit to practise. An adverse incident or outcome may provide evidence that a doctor appears to be unfit to practise, and if so, we will intervene in order to protect patients and the public interest. Our published guidance requires every doctor to take action where patients are at risk, including, if necessary, informing us. We have published detailed guidance for doctors in senior positions or with management responsibilities about what to do when a doctor's practice goes wrong. We also publish guidance for patients about how to make a complaint to the GMC. When enquirers contact us with a concern about a doctor, we give them information to help them pursue their complaint in the most appropriate way.
THE ROLE OF THE GMC
3. The GMC's duties and powers are conferred and regulated by statute. Our current powers derive from the Medical Act 1983, as amended by the Medical (Professional Performance) Act 1995 and the European Primary Medical Qualifications Regulations 1996.
4. The GMC protects the public interest by regulating the medical profession. The GMC licenses doctors to practise medicine in the United Kingdom and has four main functions:
(a) Keeping up-to-date registers of qualified doctors.
(b) Foster good medical practice.
(c) Promoting high standards of medical education.
(d) Dealing firmly and fairly with doctors whose fitness to practise is in doubt, on grounds of conduct, health or performance.
DEALING WITH DOCTORS WHOSE FITNESS TO PRACTISE IS IN DOUBT
5. Our fitness to practise procedures apply to all registered doctors. There are three complementary sets of procedures: conduct, health and performance. These procedures enable us to take action where there are concerns about a doctor's fitness to practise. Where it is necessary for the protection of patients or is otherwise in the public interest, a doctor's registration can be suspended or removed indefinitely, or made subject to conditions which limit the circumstances in which he or she can practise.
6. Action under the procedures may be triggered by any complaint (in this memorandum "complaint" also includes information) which appears to raise a question about a doctor's conduct, health or performance. It is important to note that the GMC's remit extends only to individual doctors: we cannot consider complaints against an organisation (such as a hospital) or an interdisciplinary clinical team.
7. We can take action under:
(a) The conduct procedures, if it appears that a doctor may have committed serious professional misconduct or has been convicted of a criminal offence. Serious professional misconduct means conduct which has fallen seriously short of the standards of conduct expected of doctors.
(b) The performance procedures, if it appears that a doctor's professional performance is seriously deficient, that is, the doctor is persistently failing to meet proper professional standards.
(c) The health procedures, if it appears that serious psychiatric or physical illness is affecting the doctor's ability to practise.
8. Any adverse clinical incident or outcome could potentially lead to action by us under any of the fitness to practise procedures, depending on the circumstances. However, it would not inevitably do so: some adverse incidents occur without a doctor being involved, and some occur because of unit or organisational failure rather than because of action or inaction by an individual doctor.
9. For us to become involved, there would need to be grounds to consider that the matter implied that a doctor was unfit to practise. For that reason, we would not expect to be told about every such incident. We have therefore published general guidance for every doctor and more detailed guidance for those in senior positions or with management responsibilities about the circumstances in which a doctor may need to be reported to us.
Referrral to the GMC: guidance for all doctors
10. Our guidance on the duties of a registered doctor is contained in Good Medical Practice (1998) (copy at Annex A). This booklet has been sent to every doctor on the medical register. It sets out our core guidance on standards of practice and care. Paragraphs 23 and 24 make clear that every doctor has a responsibility to take action to protect patients if another doctor's health, conduct or performance is a threat to them, and sets out what action should be taken. If a doctor is in doubt, the guidance advises consulting an experienced colleague or contacting the GMC.
Referral to the GMC: guidance for doctors in senior positions or with management responsibility
11. In July 1998, we published Maintaining Good Medical Practice (Annex B). It provides a framework for ensuring that standards of good medical practice are implemented locally through effective quality assurance. As well as giving guidance to doctors and managers on maintaining good practice and on preventing and managing poor practice, the booklet gives specific guidance on what to do when poor performance or other serious problems are discovered, and it identifies the kinds of problems which may trigger referral to us.
12. The guidance is equally applicable to the NHS and the private sector, although the mechanisms in the private sector for achieving quality assurance may differ from those in the NHS.
13. The guidance states that, where there are concerns about a doctor's practice, local policies and procedures should be followed first. (However, if a doctor appears to have been guilty of serious misconduct, has committed a criminal offence, or is already a danger to patients, the case should be referred to the GMC at once.) The aim in all cases must be to deal quickly with signs of poor practice. Whatever procedures are in place must:
(a) protect patients if they are at risk;
(c) provide support and practical help for the doctor and others directly involved.
14. Where an adverse clinical incident or outcome has occurred, a preliminary investigation will invariably need to be carried out by those with direct responsibility for the care of the patient concerned. This will ensure that the particular patient receives prompt and appropriate care, and that any organisational defects leading to the incident or outcome are identified and remedied. The preliminary investigation will also need to consider whether any further steps are necessary in order to protect patients, including whether the matter should be referred to us.
15. Our guidance makes clear that, in many cases, referral to us will not be necessary because measures can be taken locally to protect patients and to provide the doctor with any retraining or further training which may be necessary. However, the guidance contains example of kinds of serious clinical problems which would require referral to us. These are set out on pages 15-17. Any of them might arise as a result of an adverse incident or outcome.
16. The guidance also sets out what information should be sent to us. A full local investigation does not need to be carried out before a case is referred to us, but there must be enough evidence to show that there is a case to answer. That is because our powers do not allow us to take action unless there is evidence that a doctor may be unfit to practise.
17. We have established a telephone helpline for employers or medical colleagues who are concerned whether to report a doctor with problems. The helpline is run by our staff, who can arrange for callers to talk to an experienced member of the Council.
Referral to the GMC by other organisations
18. In addition to referrals made to us by those with management or contractual responsibility for a doctor, we also receive reports of investigations by bodies such as the Health Services Appeals Authority, NHS Tribunals, coroners and the police. A referral from any of these bodies might concern an adverse clinical incident or outcome.
Complaints from patients
19. We would expect that most adverse clinical incidents or outcomes would be referred to us by an organisation rather than by an individual patient. However, we do receive complaints direct from patients about such matters.
20. Our booklet for patientsA Problem with Your Doctor (Annex C)sets out how to make a complaint about a doctor, and how the complaint will be dealt with. We send the booklet to patients who contact us who may be considering making a complaint. The booklet contains a standard complaints form which complainants may use if they wish, although we will consider any complaint which is made in writing. If the complaint is taken forward, we will need the complainant to make a sworn statement, and we provide advice about how to do this.
21. If it appears from a patient's complaint that a local investigation has not been carried out (for example under the NHS procedures) but would be of benefit in obtaining information to help us assess it, we will advise the patient how to pursue the matter. We will also provide the patient with the name and address of any organisation which might be able to help, including the Community Health Council (or equivalent body in Scotland or Northern Ireland). However, if a complaint is, or may be, in our jurisdiction, we do not require the complainant to go through a local process before we will deal with it and if it appears that a doctor may be a risk to patients we will take any necessary action as soon as possible to ensure that patients are properly protected.
How we screen complaints
22. Every complaint to us is screened according to common criteria, regardless of whether it has come from an organisation or a patient. Unless it is not within our jurisdiction, a complaint is initially considered by one or more medical and lay members of Council who act as screeners. They decide if action should be taken under the conduct, health or performance procedures.
23. Adverse clinical incidents or outcomes referred to us would normally be considered as potential conduct or performance cases (although if the underlying cause of the problem is that the doctor is seriously affected by ill health, we may take action under the health procedures).
24. Some adverse clinical incidents or outcomes would be capable of being taken forward under either the conduct or the performance procedures, because "misconduct" and "poor performance" may sometimes overlap. The decision as to which route is chosen will depend on a number of factors including the gravity of the circumstances and whether the incident was part of a pattern of poor performance by the doctor or was a single episode. Other factors being equal, the conduct procedures are chosen in preference to the performance procedures because they leave open the possibility of erasing the doctor from the register (which the performance procedures do not) and because the final stage of the conduct procedures is normally held in public whereas the performance procedures are normally conducted in private.
25. Often we may need further information before deciding whether action can be taken under the fitness to practice procedures. If necessary, we will instruct our Solicitors to gather this for us.
DISCLOSURE OF INFORMATION TO PATIENTS, THEIR RELATIVES AND CARERS
The role of the doctor
26. Good Medical Practice contains guidance for doctors on how to deal with complaints from patients about the care or treatment they have received. This advice, which applies regardless of whether the GMC is involved in the particular case or not, makes clear that doctors have a professional responsibility to deal with complaints constructively and honestly, and that they should co-operate with any complaints procedure which applies to their work.
27. If a patient has suffered serious harm under a doctor's care, the guidance states that the doctor should:
(a) Act immediately to put matters right, if that is possible.
(b) Explain fully to the patient what has happened and the likely effects.
(c) Where appropriate, offer an apology.
(d) Co-operate fully with any formal inquiry into the treatment of a patient and not withhold relevant information, subject to the right not to provide evidence which may lead to criminal proceedings being taken against the doctor.
28. If a patient dies and an inquest is held, the doctor must assist the coroner.
Access to information and medical records
29. The Access to Health Records Act 1990 gives patients the right, subject to certain exemptions, to see health information about themselves which has been manually recorded from 1 November 1991 onwards. This legislation has now been incorporated in the Data Protection Act, which also gives patients the right to see information about them which is held on computer.
30. We have no role in administering this legislation, but we actively help patients who complain to us and who may need or who want to see their records, by giving them the information they need to obtain access from the record holder. Complaints about alleged failures to disclose all the information to which a patient is entitled are dealt with through the courts.
31. When a complaint is made to us, we copy it to the doctor and invite him or her to comment. We ask if the doctor would be willing for their response to be seen by the complainant, and where consent is forthcoming (as is sometimes the case) we will copy the doctor's comments to the complainant. However, if the doctor declines, we have no power to compel disclosure.
32. We are reviewing all our procedures to ensure that they remain fit for purpose in today's circumstances. This particular provision is one which we have already identified as in need of review.
1 Annexes not printed. Back